ATI LPN
ATI PN Maternal Newborn 2023 II Questions
Extract:
A nurse is assisting with the care of a client who received magnesium sulfate to treat preterm labor.
Question 1 of 5
The nurse should monitor the client for which of the following findings as an indication of magnesium sulfate toxicity?
Correct Answer: D
Rationale: Respiratory rate of 10/min is a critical sign of magnesium sulfate toxicity. Magnesium sulfate can cause respiratory depression, and a rate of 10 breaths per minute or less indicates that the patient may be experiencing toxic effects.
Extract:
A nurse is caring for a client who asks about the purpose of a Papanicolaou test.
Question 2 of 5
Which of the following responses should the nurse make?
Correct Answer: D
Rationale: This statement is correct because a Papanicolaou test is specifically designed to detect the presence of cervical cancer and precancerous changes in the cervical cells.
Extract:
Vital Signs: Heart rate: 84/min, Temperature: 37.3°C (99.1°F), Blood pressure: 128/82 mm Hg, Respiratory rate: 18/min. Diagnostic Results: Blood glucose: 120 mg/dL (Normal: 74 to 106 mg/dL). Medical History: The client is a 24-year-old female with a history of type 1 diabetes mellitus first diagnosed at 14 years of age. The client is on insulin for diabetes management. No other significant prenatal history is noted. The client is gravida 1 para 1 following a spontaneous vaginal birth at 37 weeks of gestation. The newborn was large for gestational age, weighing 4.1 kg (9 lb). The client has a third-degree laceration that required several stitches. Nurses' Notes: Client was admitted to the postpartum unit 4 hours after delivery. The fundus is firm and midline at the level of the umbilicus. Lochia is moderate. A lunch tray was given. The newborn is sleeping in a bassinet next to the client's bed. The client is diaphoretic, with skin that is clammy. Pulse is rapid, strong, and regular, and respirations are shallow. The client reports a headache, slight nausea, and feeling weak.
Question 3 of 5
Complete the following sentence by using the list of options. The nurse should plan to ___ then ___
Correct Answer: A
Rationale: The nurse should plan to check the client's blood glucose level then implement seizure precautions. Symptoms suggest hypoglycemia, common in diabetic patients, requiring glucose check and seizure precautions.
Extract:
A nurse is reinforcing teaching with a client who tested positive for group B streptococcus β-hemolytic (GBS) during a prior pregnancy and is at 30 weeks of gestation.
Question 4 of 5
Which of the following statements should the nurse make?
Correct Answer: A
Rationale: Testing for GBS at around 36 weeks of gestation is standard practice to identify carriers and prevent neonatal GBS infections through intrapartum antibiotic prophylaxis if necessary.
Extract:
Nurses' Notes: At 0625, the client is alert and oriented, at 38 weeks of gestation, presenting to the labor and delivery unit for evaluation of fluid leaking from the vagina. The client states they felt a small gush of fluid and thinks their membranes have ruptured. At 0830, mild contractions are occurring 20 minutes apart, irregular, lasting 40 seconds. The client rates the pain as a 3 on a scale of 0 to 10. An electronic fetal monitor is applied. The client voided 50 mL of clear yellow urine in a bedpan. Mild contractions are now 15 minutes apart, irregular, lasting 30 seconds. The cervix is 2 cm dilated with 20% effacement. The client rates pain as a 4 on a scale of 0 to 10. The fetal heart rate (FHR) is 132/min with moderate variability.
Question 5 of 5
The nurse is assisting with planning care for the client. After review of the client's electronic medical record (EMR), which of the following interventions should the nurse recommend as anticipated, nonessential, or contraindicated?
Options | Indicated | Non-Essential | Contraindicated |
---|---|---|---|
Encourage frequent ambulation | |||
Ensure the client maintains a supine position while in bed | |||
Check FHR every 30 min | |||
Perform a Nitrazine test | |||
Prepare the client for catheterization | |||
Obtain CBC blood sample | |||
Check the client's temperature every hour |
Correct Answer: A: Anticipated, B: Contraindicated, C: Anticipated, D: Anticipated, E: Nonessential, F: Nonessential, G: Anticipated
Rationale: A: Encourages labor progression. B: Can impede labor and fetal oxygenation. C: Ensures fetal well-being. D: Confirms rupture of membranes. E: Not needed with spontaneous voiding. F: No signs of infection. G: Monitors for infection post-rupture.